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0 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in fullforceand effect. <br /> License0L) Exp Date: 113j � j <br /> Date: Contractor_ (( G V I��I/IIY) <br /> Signature: I Title: <br /> Print Name: VlVis �� ✓Nl�e.� <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> i <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. , <br /> y 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier. Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any C <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code` ( <br /> , I shall forthwith comply with those provisio <br /> Exp. Date: q k 1z t0 Signature: �--- <br /> Print Name: C `I'Iwkr-,_ �ryyle/ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �%% _ (signature Of C-57 licensed authorized representative), <br /> hereby authorize(print name) \ (7/, = � � ST l% r ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application, <br /> e12WO21MI <br /> END]9-01 11)5e7 WELL PERWT MP <br />